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LETTER TO EDITOR
Year : 2013  |  Volume : 5  |  Issue : 1  |  Page : 56-57  

A childhood case of trichotillomania associated with body dysmorphic disorder and stigmatization due to outstanding red hair


1 Dermatology Clinic, Ahu Hetman Hospital, Marmaris, Mugla, Turkey
2 Department of Dermatology, Ac?badem University School of Medicine, Istanbul, Turkey
3 Department of Microbiology, Ahu Hetman Hospital, Marmaris, Mugla, Turkey

Date of Web Publication6-Jul-2013

Correspondence Address:
Ayse Tulin Mansur
Yunus Nadi Cad., Duzenli Apt., A Blok, No: 80/9, Armutalan, 48750, Marmaris, Mugla
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-7753.114698

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How to cite this article:
Mansur AT, Aydingoz IE, Artunkal HS. A childhood case of trichotillomania associated with body dysmorphic disorder and stigmatization due to outstanding red hair. Int J Trichol 2013;5:56-7

How to cite this URL:
Mansur AT, Aydingoz IE, Artunkal HS. A childhood case of trichotillomania associated with body dysmorphic disorder and stigmatization due to outstanding red hair. Int J Trichol [serial online] 2013 [cited 2019 Nov 14];5:56-7. Available from: http://www.ijtrichology.com/text.asp?2013/5/1/56/114698

Sir,

Body dysmorphic disorder (BDD) is a distressing preoccupation with an imagined or slight defect in appearance of a body part. [1] Trichotillomania (TTM), the phenomenon of hair pulling, is usually considered an impulse-control disorder. [2] Here, we describe a girl with TTM and BDD, caused by stigmatization due to her hair color.

A 12-year-old girl with bright red hair was referred for parietotemporal hair loss of 4-months duration, unresponsive to oral terbinafin and itraconazole. Examination showed ill-defined, noncicatricial alopecic patches [Figure 1]a-c. Hair pull test was negative. Native preparation with 15% KOH and culture on Saburaud agar yielded no fungi. Scalp dermoscopy revealed black dots, coiled fractured short hairs besides broken hairs of different lengths. There were many dystrophic hairs, some with frayed ends, sparse yellow dots, but no exclamation-mark hairs [Figure 2]a-c. All these findings led to a diagnosis of TTM. During an interview conducted by a psychologist, the patient admitted that she hated her hair color. School and play mates were calling her as "carrot head." Her parents then declared that they noticed increased hair loss after she was alone in bathroom or toilette. Though they did not directly observe hair pulling, they were convinced about the diagnosis of TTM.
Figure 1: (a-c) Patchy hair loss and unevenly broken hair shafts

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Figure 2: (a-c) Dermoscopy reveals broken hair, black dots, hair with frayed ends, sparse yellow dots

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In childhood hair disorders such as tinea capitis or alopecia areata are also common, posing diagnostic difficulties for TTM. Misdiagnosis as tinea capitis might have promoted our patient to keep on hair pulling. As patients with TTM usually deny the pulling habit, diagnosis is based on clinical, dermoscopic, and histopathologic findings. Clinical diagnosis of TTM with unevenly broken hair is straightforward. Dermoscopy of the scalp and hair in TTM improves diagnostic accuracy especially in equivocal cases for alopecia areata. The presence of black dots, coiled hair, shafts of varying lengths with fraying or split ends, and absence of exclamation mark hairs are suggestive of TTM. [3],[4] In our case, dermoscopic features were consistent with TTM, and supported our clinical diagnosis, avoiding scalp biopsy which is a traumatic procedure.

Children with TTM tend to have perfectionistic personality qualities, and among such patients BDD is especially prevalant. One of the most common areas of concern for adolescents with BDD is hair, most often excessive hair and thinning. [1] These patients often have a low self-esteem and feelings of unattractiveness, which may also be caused by stigmatization. Stigmas are attributes that spoil an individual's identity due to a perceived or actual trait. They always carry negative evaluations, therefore stigmatized individuals develop coping strategies to protect themselves. [5] Stigmatization in our patient was caused by the red hair color which is quite rare in Turkish population. This case suggests that TTM and BDD with stigmatization may overlap and hair color may contribute to all these psychopathologies.

 
   References Top

1.Albertini RS, Phillips KA. Thirty-three cases of body dysmorphic disorder in children and adolescents. J Am Acad Child Adolesc Psychiatry 1999;38:453-9.  Back to cited text no. 1
    
2.Tay YK, Levy ML, Metry DW. Trichotillomania in childhood: Case series and review. Pediatrics 2004;113:e494-8.  Back to cited text no. 2
    
3.Abraham LS, Torres FN, Azulay-Abulafia L. Dermoscopic clues to distinguish trichotillomania from patchy alopecia areata. An Bras Dermatol 2010;85:723-6.  Back to cited text no. 3
    
4.Inui S. Trichoscopy for common hair loss diseases: Algorithmic method for diagnosis. J Dermatol 2011;38:71-5.  Back to cited text no. 4
    
5.Berjot S, Gillet N. Stress and coping with discrimination and stigmatization. Front Psychol 2011;2:33.  Back to cited text no. 5
    


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  [Figure 1], [Figure 2]



 

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